Exam III: Shoulder, Hip, Developmental, and Soft Tissue Structures Flashcards
Duerr
shoulder lecture
You extend a dog’s shoulder to test for pain, the dog shows sign of pain, what do you have to rule out?
elbow pain, you cannot extend the shoulder wihtout extending the elbow.
shoulder
What predisposes our canine specie to OCD? How does it present and what are some of your differentials? What is the treatment?
OCD can be due to gentics, butritions (excessive Ca, high calorie/protein), or elbow dysplasia and panosteitis (juveniles)
signalment and history is usually large and giant breeds (juveniles), lameness will be unilateral but can be bilateral, lameness may wax and wane or disappear: !!
if there is a wax and wane lameness or if it disappears, you want to rule out the dislodgement of a fragment causing synovial osteochondroma formation or bicipital tendinopathy (when there is a piece just irritating the biceps).
during PE, there will be pain mainly on FLEXION, but can also be during extension and rotation. You can diagnose with radiographs (do both legs), CT, and arthrogram (contrast).
treatment surgically includes osteochondroplasty (flap removal) or osteochondral autograft transfer (OATS) then OA management.
shoulder
When would you suspect medial shoulder instability (MSI) in a dog? What are your rule outs? what are the diagnostic tests and treatment options?
what structures are involved?
If an agility (flyball, hunting, etc) dog came in with mild-moderate chronic lameness, decreased performance, or a change in gait (2 vs 1 footed weaves), I would begin to suspect MSI.
the shoulder would be painful on abduction
MSI is also called “syndrome” because instability is not always present. when instability is not present, I would want to rule out osteosarcoma (if you remember, they love the proximal humerus). Radiographs will show mild OA or normal, and there will ne a subjectively increased abduction angle (normal is 32.6 +/- 2 degrees, 26 for medium to latge breed dogs). Acquiring the abduction angle requires sedation and full extension of the elbow and shoulder and a GONIOMETER is used.
conrimatory diagnosis includes arthroscopy (which shows intra-articular components of MGHL and sunscapularis), MRI for all intra- and extra-articualr structures (besides cartilage) and ultrasound which is the cheapest option.
surgical treatment options include radiofrequency shrinkage, tendon transposition, and prosthetic ligament reconstruction (which is not easy so…) - we like to try rehab first.
other noninvasive treatment options for low grade MSI includes hobbles, theraband, shock wave…
MGHL and subscapularis
shoulder
What are the primary and secondary etiologies for BICEPS/SUPRASPINATOUS tendinopathies?
What us the common clinical presentation?
How is it diagnosed? Treatment?
Primary is due to repetitive microtrauma (signalment of large/active dogs), trauma, and overuse. Secondary (biceps) is due to irritation/inflammation/ other joint disease (OCD, supraspinatus, MSI)
the typical signalment will be middle-aged, medium/large breed athletic dogs with a histpory or progressive lameness that is exacerbated with exercise.
We want to rule out elbow dysplaisa and degenerative joint disease with raadiographs and CT (to see if elbow is involved). OA and looking at proximal humerous for OSA on (good) radiographs. and also doing your neuro exam (check the reflexes, conscious proprioception, anisocoria > look the dog in the eyes for horners syndrome that points to brachial plexus tumor)
Diagnosis is by PALPATION of the biceps (extend elbow, flex shoulder), and the supraspinatuous where you want to palpate the insertion on the greater tubercle to check for pain and shoulder flexion while the elbow is flexed.
Also, XRAYS, arthorgram (for biceps only), ultrasound and MRI, and arthroscopy (but remember the supraspinatous is not seen here). Also use joint blocks to enure not just incidental findings.
US for dynamic checks
Treatment is usally Pt/Rehab for both. Traimcinalone in the joint, shock waves and PRP (platelet rich plasma) for supraspinatuos… surgical options (biceps: tenodesis and tenotomy) (supra: tendon resection, release of transverse humeral ligament, release incisions in supraspinatous) not often used.
Xrays are helpful for calcifying tendinopathies
the supraspinatous muscle originates on the supraspinous fossa and insters on the greater tubercle (caudal). the biceps originates on the supraglenoid tubercle and inserts on the radial and ulna tuberosities.
shoulder
You see a dog with hip or carpus OA, what does NOT belong on your differentials list?
OCD
OCD only occurs in the shoulder, elbow, stifle and tarsus
hip
How would one diagnose Traumatic Hip Luxation and what are the treatment options?
open vs closed?
you can do either a closed or open reduction.
if closed reductions are successful and it is a dorsal luxation, you can try and Ehmer sling for 10-14 days whihc internall rotates the leg and adducts it so it stays in place. can also use “DogLegg’s” which has less soft tissue complications. For ventral luxations, there is Hobbles which prevents abduction, you want to avoid the dog splaying out.
If closed reduction is unsuccessful, you can try open and stabilization if there is good hip conformation. FHO (femoral head and neck osteoctomy/excision) is a salvage proceduer that elimates bony contact between the acetabulum and femoral head and creates fibrous pseuoarthrosis.
A total hip replacement may also be indicated if there is poor hip conformation, especially in larger dogs. Just not expense.
hip
How do you diagnose Legg-Calve-Perthe disease and what are the treatment options?
LCP is non-inflammatory, aseptic necrosis of the femoral head, it looks like lysis and my get confused with a tumor.
the breed commonly affected are toy and terrier breeds, signalment 3-12 months (usually 5-8). There is a 15% chance of bilateral involvement and you will need to differentiate with MPL or it could happen concurrently.
hip
What is the pathology behind CHD (canine hip dysplasia) and appropriate diagnostic procedures for juvenile vs adult dogs?
What are your differentials with pain on saggital plane ROM?
femoral head coverage by the acetabulum should be >50%
saggital plane ROM pain differentials include HD, CCLD, neuro and flexor muscle dz, in the frontal plane, HD and adductor muscle dz. Pain on adduction is more likely the hip. flexing the stifle would confirm it.
palpation tests for juveniles in the ortolani, PennHIP (assesses the DI (distraction index) which when <.3 means no OA, >.7 means OA and in between is a grey zone)
in adults, the gait would be abnormal and you wouldn’t have a positive ortolani becasue they are so arthritic and PennHIP is not needed. OFA-like is always sufficient. if the radiographs are normal (no OA), you can rule out hips.
hip
when would a JPS, TPO, FHNE, and THR be indicated?
compare JPS to TPO
JPS (juvenile pubic symphysiodesis) is still a good choice for dogs less than 5 months old, so an early diagnosis is crucial. JPS may go up to 24 weeks in a large breed dog.
if they are greater than 20 weeks (up to 8-9 months of age), pelvic osteotomies (TPO and DPO) are an option
JPS and TPO are both used to accomplish more coverage of the femoral head (and tighten hip joint (TPO)). TPO is indicated in patients 6-12 mo with no clinical symptoms, no significant DJD, and adequate dorsal actebaulr rim (DAR, acetabulum needs to be normally shaped)
JPA has more pros (both hips, less to no complications, less invasice, cheaper and easier) than TPO (only benefit is that you can catch them at 6-12 months)
Adult treatment options include FHO and THR - but it’s very important to try medical management first (omega-3 fatty acids and weight loss/control). THR has long term loosing and failing affects. results are variable for FHO and it is NOT advised in juvenile patients.
You CANNOT THR after an FHO
DOD (developmental orthopedic disease)
The student should be able to describe the differences in diagnosis and management of the following conditions in small animals:
Osteochondrosis dissecans
Panosteitis
Hypertrophic osteodystrophy
Hypertrophic osteopathy
include treatment
- OCD: (DOD) the disruption of endochondral ossiication, can have a osteochondral (with sunchondral bone) or cartilaginous flap in the shoulder, elbow, tarsus, or stifle.
clinical signs: pain, effusion, lameness
diagnosis: flattening of caudal femoral head in rads
treatment: flap removal (preserve if you can), OATS and regenertative medicine.
- Panno: 7-16 mos (teenagers) but reported to occur up to several years of age, rapidly growing larger and giant breeds, german shepards, 80% males. idopathic and osseous compartment syndrome due to a protein rich diet (compartment swells inside cortex and hard for cells to survive)
diagnosis: acute SHIFTING limb lameness and pain with direct pressure over affected DIAPHYSEAL region. increased radiodensity in marrow on rads (but has a 7 day lag behind clinical symptoms!!)
treatment: self-liming, check diet, NSAIDs, good prognosis.
- HOD: metaphyseal osteopathy, disruption of metaphysela trabeculae in long bons of young, rapidly growing dogs (age 3-6 mo, as early as 2, giant/large breed dogs, males more common and may involve several or all littermates) in the radius, ulna, tibia and mandible.
clincial signs: limp to non-weight bearing to RECUMBENT. swollen hot painful METAPHYSIS usually bilateral, SICK (fever, depression, anorexia, diarrhea, weight loss), clin path usually normal (leukocytosis, mild anemia, bacteremia is rare)
diagnostics: double physeal line on rads, irregular periosteal proliferations at the metaphyseal level, maybe later: retained cartilage cores, premature physeal closure, diaphyseal lesions.
treatment: supportive care, if severe: advanced supportive care: enteral nutrition, antibiotics
- HOA: diffuse periosteal reaction around distal bones associate with thoracic/abdominal mass. most commonly associated with paraneoplasia.
clincal signs: lethargy, anorexia, unwillingness to move, swollena and painful extremities
diagnostics: PE, US, rads (thoracic and abdominal and limb)
treatment: remove primary lesion
soft tissues
How would you repair the SDF or DDF?
As they are large tendons, you would want to use the three loop pulley pattern to repair. then put them in a walkin bar for 6 weeks and soft padded for 2 after. want them to continue to weight bear, not rest.
soft tissues
a dog presents with an achilles tendinopathy with a crab-claw-like stance, what can be deduced about tendon injuries?
the SDF is still intact. if there was a flat paw with stifle extension, that would be a complete rupture of all components of the common canlcaneal tendon.
soft tissues
how would you repair a flat or small tendon? large?
what is one thing to keep in mind?
baseball tendon repair for flat
locking loop (modified kessler) for small
three loop pulley for larger tendons.
you want a suture pattern that avoids a >3mm gap.
